EASY DEBIT AUTHORIZATION FORM
for auto payments to
RAIN Network
for monthly Internet service fees
Name:
Street Address:
City/State/Zip:
Phone:
Username(s):
AGREEMENT
I hereby authorize the RAIN Network and their financial institutions
to deduct my monthly service fees directly from my charge account
using the following information:
Bank / Branch of charge account:
Number of Account:
Expiration date if charge:
Monthly fee I authorize for debit (choose one):
___ Individual Account ($18/month)
___ Business Account ($25/month)
___ Other ($_______/month)
Description:
I understand that this payment method will provide an easy payment
method for my monthly RAIN service fees, and will commence 90 days
from my current due date. Should I decide to discontinue RAIN service
for any reason, I will notify RAIN in writing/by email at least 15
days before my account is due to terminate this payment agreement.
Signature:
Date:
Send to RAIN, 1129 State St Ste A6, Santa Barbara CA 93101-2723 or fax
to (805) 899-8698.
DO NOT RETURN THE AUTO-DEBIT FORM VIA E-MAIL. This form must be sent
with your original signature.